Feeding assessment and paediatric dysphagia — branching viva

Station opening

Examiner: "Define paediatric dysphagia and outline your approach to a child referred with possible swallowing difficulty." [1]

Strong candidate (must-hit)

• Defines paediatric dysphagia as difficulty moving food, liquid or saliva safely from the mouth to the stomach, most often from oropharyngeal phase failure in a neurologically impaired or anatomically abnormal child; frames the approach around the mealtime, chest and growth doors, the high-risk background, the clinical feeding evaluation and its named limitation, the instrumental study to confirm aspiration, and a multidisciplinary plan from texture and posture modification to enteral feeding; states that the bedside evaluation cannot exclude silent aspiration is the single most important practical principle. [1] [3]

Weak candidate

• "Dysphagia is difficulty swallowing, and I would watch a feed at the bedside and reassure the family if it looked fine." [3]

Branch A — The cough-free child with cerebral palsy

Examiner: "A six-year-old with severe cerebral palsy has had three pneumonias in a year and is faltering in weight. Her bedside feed is quiet and cough-free. Does that reassure you, and what is your next step?" [7]

Strong

• Explains that the cough-free bedside feed does not reassure, because the neurological injury that discoordinates the pharyngeal swallow also blunts the laryngeal cough reflex, so this child is aspirating silently and presenting through the chest and the growth chart; the next step is a videofluoroscopic swallow study to confirm and characterise aspiration, grading severity with the Eating and Drinking Ability Classification System, and the management is likely a gastrostomy given unsafe and insufficient oral intake. [7] [9]

Weak

• "She is not coughing, so her swallow is safe and I would treat the pneumonia and fortify her food." [3]

Branch B — The premature infant who desaturates with feeds

Examiner: "A six-week-old infant born at twenty-seven weeks desaturates and pauses breathing with each bottle feed. How do you assess the swallow, and what do you do immediately?" [4]

Strong

• Explains that the premature infant has an immature suck-swallow-breathe pattern that desaturates and apnoeas with feeds; assesses the swallow with the bedside evaluation plus fibreoptic endoscopic evaluation of swallowing at the cot side, which shows pharyngeal and laryngeal anatomy, residue, penetration and aspiration with real milk; immediately pauses the oral feed, protects the airway, suction feeds and secretions, and secures hydration and nutrition by nasogastric tube while advancing oral feeding as coordination matures. [4]

Weak

• "Preterm babies always do this; I would keep feeding and watch the monitor." [1]

Branch C — The toddler with a laryngeal cleft

Examiner: "A two-year-old with a known laryngeal cleft chokes on thin liquids. Is this a coordination problem, and how do you confirm the mechanism?" [6]

Strong

• Explains that this is a structural rather than a purely coordinative problem, because a laryngeal cleft leaves a gap between the posterior larynx and the oesophagus through which feed and saliva pass directly into the trachea regardless of swallow skill; confirms the mechanism by combining the videofluoroscopic swallow study with airway endoscopy, and the definitive fix is surgical closure of the cleft, with feeding and airway protection held in the meantime. [6]

Weak

• "I would thicken his fluids and assume it is cerebral palsy." [1]

Branch D — The family who asks why a swallow study is needed

Examiner: "A family asks why their child needs a videofluoroscopic swallow study when the bedside feed looked fine. How do you explain the rationale?" [3]

Strong

• Explains that the clinical feeding evaluation looks at the child from the outside and cannot see the bolus in the pharynx or below the vocal cords, so it misses aspiration, especially the silent aspiration that is common in neurologically impaired children, as the Calvo systematic review established; the videofluoroscopic swallow study uses X-ray to watch the barium bolus in real time and directly shows penetration, aspiration and residue, so it is the test that proves whether the swallow is safe and which consistencies can be trusted. [3] [1]

Weak

• "It is just a routine check we do." [3]

Close

Examiner: "Summarise your approach to the child with suspected paediatric dysphagia in one sentence." [1]

Strong

• "Paediatric dysphagia is difficulty swallowing that risks aspiration: I recognise it through the mealtime, chest and growth doors in a high-risk child, do a clinical feeding evaluation but never trust it to exclude aspiration, confirm and characterise the swallow with a videofluoroscopic swallow study or fibreoptic endoscopic evaluation of swallowing, and build a multidisciplinary plan that modifies texture and posture, secures nutrition, and moves to enteral feeding when the swallow is unsafe." [1] [3]